ATTACHMENT C.6.A UNITEDHEALTHCARE MANAGEMENT INFORMATION SYSTEM · 2020-06-19 · ATTACHMENT C.6.A...
Transcript of ATTACHMENT C.6.A UNITEDHEALTHCARE MANAGEMENT INFORMATION SYSTEM · 2020-06-19 · ATTACHMENT C.6.A...
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RFP 758 2000000202 Page 1 of 31
ATTACHMENT C.6.A UNITEDHEALTHCARE MANAGEMENT INFORMATION SYSTEM
A detailed description of the UnitedHealthcare Management Information System (MIS), including diagrams and flowcharts, is provided herein. The diagram on the next page provides an overview of the major capabilities and systems planned to support the Commonwealth. Following this overview diagram, we provide flowcharts or diagrams corresponding to RFP Section C.6.a.i-viii along with summary tables containing descriptions of how the subsystems are used in managing a particular operational area, dataset and transactional function.
Our Reporting subsystems are presented and described herein in subsection C.6.a.ix. Our Testing subsystems are described in subsection C.6.a.x. Descriptions of our Information Systems Management subsystems are provided in subsection C.6.a.xi. These subsystems enable user-friendly means for enrollees to access services, get information, and to be empowered to improve their health and well-being.
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FIGURE 1: C.6.A MANAGEMENT INFORMATION SYSTEM OVERVIEW
Provider ManagementClaims Processing Engine (CPE) - Optum Transaction Validation
Manager (OTVM) EDI Claims Intake, HIPAA Compliance, Quality, and Routing Enhanced Claim Edits
Interactive Voice Response (IVR) System Call Routing, Claims and Eligibility / Enrollment Status
Encounters Management
National Encounter Management Information System (NEMIS)
Encounters Processing for Medicaid
Member Management
myuhc.com & UnitedHealthcare Mobile App Profile, Claims Status, Prior Auth Status, Member Status, EOB, Electronic Communications
Advocate4Me & Task Tracker Intelligent Call Routing, Claims and Eligibility / Enrollment Status, and Welcome and Reminder Campaign Management
External UnitedHealthcare Community Plan
ConsumerDatabase
(CDB)
Claims Management
enrollee
Analytics
Online Provider Search Provider Directory Search from a web
care coordinator
Care Management
Impact Pro Identification & Risk Stratification
CSP Facets Member Enrollment Provider Network Data Claims Processing Provider Agreements Pricing and Adjudication
Claims Payment EOB and Remittance
Capitation Payments Member Benefits
Third Party Liability
MACESS Claims Paper Claims Imaging and Claims Routing
NetworX Provider Contracts and Pricing
Prospective 2.0 Pre-Payment Fraud and Abuse
Smart Audit Master (SAM) Post Payment Claim Review
iCES Facility and Professional Claims Editing
Strategic Management Analytical Reporting Tool (SMART) & Crystal Reports Integrated Analytical Data Reporting Ad Hoc Reporting Big Data Platforms
ICUE
Utilization Management
Service Authorization
ClaimSphere Predictive NCQA HEDIS Compliance & Provider Profiling Clinical Data Quality Management
UnitedHealthcare –�Kentucky Architecture
HIPAA Gateway HIPAA Transaction Mapping & Compliance
Financial Management
FTS Financial Tagging Service
FSDB Consolidated Financial Systems Database
Escalation Tracking System (ETS) Grievances and Appeals
Information Technology Management
ServiceNow Issue Tracking, Change Management, System Monitoring, & Reporting Critical Incident Data
PeopleSoft Accounting and HR Management
Ver.1.1 - Updated 01/25/20
UHCCommunityPlan.com Community Plan Informational site
CSP Call Center, Avaya Qfinity Call Center Inquiries, Statistics
call center
WebStrat Claims Reimbursement using DRG and Ambulatory Groupers
MedReview DRG Validation on Claims
B2B External Customer Gateway
Transaction Routing, EDI, HIPAA 5010, XML, State Interfaces
medical & behavioral
healthproviders
NDB and Contract Management Provider Network Management Provider Agreements
Network Database
CommunityCareTM
Community-Based Case Management
Person Centered Care
Care Management
Complex Case management
Care Plan & Service Plan Development
Automated Care Transitions
Clinical Information
Medication Management
Electronic Case Management
Clinical Records
SMART
CSP Facets
Provider Recommendation Engine (PRE) Member PCP assignment
Doc360 Scanned Paper Document Storage
UHCprovider.com and LINK Dashboard Application dashboard and messaging portal Provider Portal, Profile Management Claims and Member Status, Prior Authorizations
CommunityCareTM Care Collaboration, Patient Registry, and
Automated Care Transitions
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Attachment C.6.a UnitedHealthcare Management
Information System
RFP 758 2000000202 Page 3 of 31
C.6.a.i Enrollee Subsystems The flowchart following the table depicts how our enrollee systems supporting eligibility and enrollment receive eligibility files, then route the data contained from the files to various operational areas for day-to-day enrollment and eligibility activities such as care coordination, PCP assignment, eligibility verification, claims and related services. The summary table below provides the name of the subsystem and a description of the system’s support functionality.
Table C.6.a.i Enrollee Subsystem Descriptions
Management Information System General Description/Functions Supported by System
Subsystem: Enrollee
Alvar Monitors and tracks important business operations, transactions and processes to provide dashboards across end-to-end process flows.
B2B/Electronic Communication Gateway (ECG)
Suite of tools supporting secure EDI transactions and file transfers between UnitedHealthcare and external parties.
Business Process Management System (BPM)
Manages the enrollment error queues including corrections and resubmission of records to CSP Facets.
Consumer Database (CDB) Consolidated database of all UnitedHealthcare Enrollees that serves as a “master index” of Enrollees across all UnitedHealthcare systems.
CSP Facets Integrated managed care information system built on the TriZetto Facets platform, which meets all applicable state and federal laws and privacy regulations including, but not limited to, HIPAA. Functions include:
Core health plan administration system’s primary functions: benefits, enrollment and disenrollment management, claims pricing, adjudication and payment
Comprehensive Enrollee database, using Medicaid state ID numbers; eligibility begin and end dates; age-specific information; enrollment history; Enrollee TPL coverage and utilization and expenditure information
Integrated claim processing suite including claim edits, adjudication, COB processing, rules-based correction/adjustment, voiding and resubmission
Claim status data including incurred claims, processing status and payment timeliness data
Documents distribution of capitation payments
Generates explanation of benefits, remittance advice, and statements
Data for provider payment issuance purposes
Eligibility Enrollment Management System (EEMS)
Enhanced enrollment module for CSP Facets that increases efficiency and accuracy of the enrollment process, improved speed to market for format changes, reduced maintenance costs and improved end-to-end cycle time for loading eligibility.
Interactive Voice Response (IVR) System and Avaya Dialer
Handles basic Enrollee inquiries and directs incoming calls to the most appropriate Enrollee services center professional.
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Information System
RFP 758 2000000202 Page 4 of 31
Management Information System General Description/Functions Supported by System
MACESS Workflow application that facilitates claim processing, including viewing of paper claims and supporting documentation in EDMS and Doc360, and routing of claims to our claim processors.
Provider Recommendation Engine (PRE)
Intelligent rules engine that systematically matches Enrollees with “preferred” PCPs who have the highest quality scores and best outcomes, costs and location.
Public Enrollee Portal (uhccommunityplan.com)
UnitedHealthcare public web presence used for posting general information, handbooks and bulletins — common entry point for Enrollees. Provides flexible search capability by type of provider, specialty, location and other criteria.
Strategic Management Analytic Reporting Tool (SMART)
Comprehensive, integrated analytical data warehouse, using the latest Oracle Exadata Database platform that holds all Medicaid relevant information — including claims data (e.g., medical, pharmacy, vision and lab), Enrollee data, provider data, authorizations, external subcontractor data and predictive modeling information. SMART:
Supports quality management, performance management and compliance reporting, and ad hoc reporting as needed with turnaround times averaging less than five business days
Stores service-specific data that includes behavioral health, LTSS, pharmacy, inpatient and outpatient services
Includes consolidated patient census (common store of all patients receiving care)
Consolidates data for Impact Pro health-risk modeling and stratification
Consolidates relevant data for ClaimSphere EPSDT and HEDIS reporting and related analysis and monitoring
Secure Enrollee Mobile App (UnitedHealthcare)
The free Enrollee mobile app provides personalized care notifications, medication management capabilities, administrative transactions, and can connect users directly with a member service advocate (MSA).
Secure Enrollee Portal (myuhc.com) Secure health and wellness information is available 24 hours a day, seven days a week through our Enrollee portal. Enrollees register for online access by setting up a secure HealthSafe ID™ and password. The personalized and easy-to-navigate digital experience allows Enrollees to search for covered benefits (medical, dental, vision, pharmacy and mental health), manage personal preferences, update contact information (including email addresses for facilitating contacts and information exchange), view/print and request we mail an ID card, change their PCP and locate providers through a searchable provider directory. The portal also offers personalized health and wellness content such as seasonal reminders (i.e., flu shots), personalized care recommendations, links to plan programs, and links to online resources and tools.
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Information System
RFP 758 2000000202 Page 5 of 31
Eligibility Files
(KY)
1
Enrollee Subsystems: Eligibility and Enrollment
EDI
(Clearinghouses,
Subcontractors)
C&S Data
Warehouse and
Analytics
(SMART)
All Data
The Commonwealth sends the enrollment /
disenrollment files to UnitedHealthcare
834 is validated for HIPAA compliance and is run
through business rules
Facets service updates the Enrollee�s demographics
eligibility. Errors are captured and routed to Enrollee
Services for review
Electronic Communication Gateway (ECG) receives the
files over a secure connection
1
2
3
5
6
7
4
9
ALVAR monitors the activity for the incoming and
outgoing files
Operations and state specific reports are generated and
distributed using ECG
8
Enterprise Service
Layer
(B2B)
270/271
Portals, IVR
(UnitedHealthcare,
myuhc.com, Link,
etc)
Claims Platform
Intake
(ECG/B2B)
Pre-Processing
(EEMS/
CSP Facets)
Enrollment &
Assignments
(CSP Facets)
Facets
Inquiry &
ResponseEligibility
Reporting
(CSP Facets)834
2 3
Activity Monitoring
(ALVAR)
4
5 6
PCP assignment occurs based on business rules
11
SMART loads data from claims systems and other sources for
reporting and analytics use
Enrollee Services reviews inquiries and updates CSP Facets.
10
11
12
Data is shared with downstream systems such as the 270/271
transaction, IVRs, portals, and mobile applications.
Subcontractors
(e.g. Rx, Dental,
Vision)
834 or Proprietary
Internal Systems
(CDB, Clinical)
Fulfillment
(ID Cards,
Welcome Kits)
12
Enrollment and Eligibility updates are shared with downstream
applications and subcontractors using ECG
Workflow Mgmt.
(MACESS)
Enrollee Services
(e.g. PCP
Changes)
Inquiry &
Changes
Exception
Handling
(BPM)
PCP Assignment
(PRE)
7
8 9
10
Enrollee Services corrects errors and submits records for
reprocessing
KY State Reports
Enrollment
Errors
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Attachment C.6.a UnitedHealthcare Management
Information System
RFP 758 2000000202 Page 6 of 31
C.6.a. ii Third Party Liability (TPL) Subsystems Our third party liability (TPL) subsystems work in conjunction with our claims and utilization review subsystems to continually mine for TPL and to apply coordination of benefits (COB) edits, making sure that Medicaid is the payer of last resort. The table below provides a summary of our TPL subsystems. The flowchart following the table depicts how claims flow through our claims platform, CSP, to be adjusted due to TPL, COB, subrogation and similar cost avoidance activities.
Table C.6.a.ii.: Third Party Liability Subsystem Descriptions
Management Information System General Description/Functions Supported by System
Subsystem: Third Party Liability
CSP Facets Integrated managed care information system built on the TriZetto Facets platform, which meets all applicable state and federal laws and privacy regulations including, but not limited to, HIPAA. Functions include:
Core health plan administration system’s primary functions: benefits, enrollment and disenrollment management, claims pricing, adjudication and payment
Comprehensive Enrollee database, using Medicaid state ID numbers; eligibility begin and end dates; age-specific information; enrollment history; Enrollee TPL coverage and utilization and expenditure information
Integrated claim processing suite including claim edits, adjudication, COB processing, rules-based correction/adjustment, voiding and resubmission
Claim status data including incurred claims, processing status and payment timeliness data
Documents distribution of capitation payments
Generates explanation of benefits, remittance advice, and statements
Data for provider payment issuance purposes
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Information System
RFP 758 2000000202 Page 7 of 31
Claims Platform
COB Verification on Claim
(CSP Facets)
TPL Files /COB Information
(DMS, Others)
Third Party Liability Subsystems
Claims
Verify Enrollee COB
(CSP Facets)
4
COB Claims
COB Claims
Continue Claim Adjudication
(CSP Facets)
9
Claims Payment(CSP Facets)
10
Apply COB Information
(CSP Facets)
8
Claim is loaded into Facets pre-processer. Enrollee and Provider on the claim are identified
Verify if COB information is submitted on claim
1
2
3
4
7
11
8
CSP Facets finalizes and pays claim
5
Provider submits claims via either clearinghouse or directly. Submitted are transmitted to CSP Facets
Verify if Enrollee has COB information loaded within CSP Facets and pend claim
Review COB to validate the COB information on claim in CSP Facets
Apply appropriate COB information to claim in CSP Facets
CSP Facets completes adjudication and readies claim for payment
Claim Submission
1
Pend Claim for Review
(CSP Facets)
5
Review Claims per COB
Guidelines(CSP Facets)
6
9
TPL and COB information from the Commonwealth and other entities are loaded into CSP Facets via ECG
7
Subcontractors(Rx, Vision, Dental, etc.)
11
Enrollee COB/TPL Information
(Commonwealth)
12
6 CSP Facets pends the claims for COB review
10
We continually update COB information and share those updates with the Commonwealth via ECG
12
TPL updates are shared with our subcontractors
Claims Pre-Processing
(CSP Facets)
2
3
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Attachment C.6.a UnitedHealthcare Management
Information System
RFP 758 2000000202 Page 8 of 31
C.6.a.iii Provider Data Management Subsystems The flowchart following the table below illustrates how provider data is collected from internal and external sources, and then loaded into other subsystems for day-to-day business operations, such as provider directories, claims, contracting and our secure provider portal, Link. Our Provider Subsystem supports online inquiry screens and external interfaces with the Department and other governmental agencies to receive licensure information. The table below describes the systems supporting our provider data management system as a whole.
Table C.6.iii.: Provider Data Management Subsystem Descriptions
Management Information System General Description/Functions Supported by System
Subsystem: Provider Data Management
Aperture
Manages workflow and stores provider credentialing information for all UnitedHealthcare participating providers
B2B/Electronic Communication Gateway (ECG)
Suite of tools supporting secure EDI transactions and file transfers between UnitedHealthcare and external parties
CSP Call Center Supports Enrollee services center operations in assisting providers with common inquiries (e.g., verifying Enrollee eligibility and verifying claims status)
Exari
Manages provider contracting workflow and stores contract information for most UnitedHealthcare participating providers
Interactive Voice Response (IVR) System
Enterprise voice portal handles basic provider inquiries (e.g., Enrollee eligibility/enrollment status and claims status) and directs incoming calls to the most appropriate provider services center professional
Link Secure provider portal providing a central access point where enrolled providers have access to eligibility and benefits, claims management, claims reconsiderations, enhanced online authorizations and gaps in care, and where they can update their practice profile. Additionally, providers can view and provide feedback on the initial health risk screening and care plans in CommunityCare.
Network Database (NDB) Our single enterprise repository of all information related to provider network management
Provider Elastic Search Tenant (PES) PES leverages the UnitedHealthcare Big Data Platform to return real-time, current provider data to client-facing applications.
uhccommunityplan.com UnitedHealthcare public web presence used for posting general information, handbooks and bulletins and serves as a common entry point for providers
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Information System
RFP 758 2000000202 Page 9 of 31
Management Information System General Description/Functions Supported by System
UHCprovider.com UHCprovider.com is UnitedHealthcare's home for provider information. With access to Link’s self-service tools 24 hours a day, seven days a week, current medical policies and the latest news bulletins, this site also has a great library of resources to support administrative tasks including eligibility, claims and prior authorizations and notifications. UHCprovider.com includes a powerful internal search tool to help care providers locate the information they need quickly. The site also offers care providers the opportunity to submit feedback on their experience to help identify opportunities to improve or enhance how we work together.
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Attachment C.6.a UnitedHealthcare Management
Information System
RFP 758 2000000202 Page 10 of 31
Online and
Mobile Provider
Directories
(Find Care)
Interactive
Voice Response
(Enterprise Voice
Portal)
Encounters
Processing
(NEMIS)
10
Credentialing
(Aperture and
Provider
Onboarding)
Commonwealth
(KY)
Secure
Provider Portal
(Link)
Commonwealth�s
Provider Data
(KY)
Reconcile Provider
Data
(CAQH)
Provider
Contracting
(Exari)
3
2
Provider contracts with UnitedHealthcare
Provider data is received from the Commonwealth and loaded to
NDBSource of Truth for Provider Data
Encounters are created for paid claims and are validated prior to
sending them to the Commonwealth
Providers can obtain claims status, claim payment information,
member eligibility, data validation, reports, authorizations, and
more on secure provider portals
Council for Affordable Quality Healthcare's (CAQH) data is
received and reconciled with UnitedHealthcare�s provider data in
NDB
1
2
4
5
7
8
9
Provider data is sent daily to our online provider directories
10
Provider Subsystem
Provider
Demographics,
Credentials, and
Contracts Loading
(NDB)
1
Provider Load and
Claims Processing
(CSP Facets)
5
8
9
Data Warehouse
and Analytics
(SMART)Provider Data
6
4
Provider data is loaded daily to the CSP Facets Claims Platform6
Provider and claims data is loaded into the Data Warehouse for
analytics and reporting
11
HEDIS Measures
and Gaps in Care
(ClaimSphere)
11
12
13
CAQH Data
Contract Data
Demographics,
Credentials,
and Contract
Data
837
NCPDP
Processed
Claims
Web Services
Provider
Demographics
All Claims
and Provider
Data
Web Services
Providers can obtain claims status, member eligibility, and more
via the IVR system
13
12
Claims and
Provider Data
Provider and claims data is sent to ClaimSphere to calculate
HEDIS Measures
Credentials and
Primary Source
Verification data
Provider credentials are verified and data is loaded in NDB3
Provider Search
Tenant
(PES)
7
Provider data is loaded daily to the search tenant for use by other
systems
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Attachment C.6.a UnitedHealthcare Management
Information System
RFP 758 2000000202 Page 11 of 31
C.6.a.iv Reference Subsystems Interwoven with each relevant operational need for data (e.g., claims, utilization, quality management) are contract-specific reference sources and the detailed information needed to manage and maintain up-to-date pricing files as well as procedure codes and diagnosis codes (i.e., reference data) specific to that contract. Also, our Reference Subsystems support online inquiry screens and interfaces with critical reference data from external sources, such as but not limited to ADA (dental) codes, CMS-HCPCS updates, CPT4, ICD-9, ICD-10, diagnosis surgery codes (e.g., DSM), and NDC codes.
Table C.6.iv.: Reference Subsystem Descriptions
Management Information System General Description/Functions Supported by System
Subsystem: Reference Subsystems
CSP Facets Integrated managed care information system built on the TriZetto Facets platform, which meets all applicable state and federal laws and privacy regulations including, but not limited to, HIPAA. Functions include:
Core health plan administration system’s primary functions: benefits, enrollment and disenrollment management, claims pricing, adjudication and payment
Comprehensive Enrollee database, using Medicaid state ID numbers; eligibility begin and end dates; age-specific information; enrollment history; Enrollee TPL coverage and utilization and expenditure information
Integrated claim processing suite including claim edits, adjudication, COB processing, rules-based correction/adjustment, voiding and resubmission
Claim status data including incurred claims, processing status and payment timeliness data
Documents distribution of capitation payments
Generates explanation of benefits, remittance advice, and statements
Data for provider payment issuance purposes
NetworX Supports rules-based provider contract configuration and claim pricing
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Attachment C.6.a UnitedHealthcare Management
Information System
RFP 758 2000000202 Page 12 of 31
C.6.a.v. Claims Processing Subsystem (including Encounter Data) Working in conjunction with our TPL and SURS subsystems described and provided in this attachment, our claims processing and encounter data systems bring workstreams together to enable effective management of each process. Following the table below, we provide two flowcharts that depict how our encounter data processing and our claims processing systems interconnect.
Table C.6.a.v.: Claims and Encounters Processing Subsystem Descriptions
Management Information System General Description/Functions Supported by System
Subsystem: Encounter Data and Claims Processing
B2B/Electronic Communication Gateway (ECG)
Suite of tools supporting secure EDI transactions and file transfers between UnitedHealthcare and external parties
Claims Processing Engine (CPE) Application that enables universal claim intake and routing into CSP Facets
Claims Rules Engine (CRE) Application to support the business rules and validations used during claim adjudication.
CSP Facets Integrated managed care information system built on the TriZetto Facets platform, which meets all applicable state and federal laws and privacy regulations including, but not limited to, HIPAA. Functions include:
Core health plan administration system’s primary functions: benefits, enrollment and disenrollment management, claims pricing, adjudication and payment
Comprehensive Enrollee database, using Medicaid state ID numbers; eligibility begin and end dates; age-specific information; enrollment history; Enrollee TPL coverage and utilization and expenditure information
Integrated claim processing suite including claim edits, adjudication, COB processing, rules-based correction/adjustment, voiding and resubmission
Claim status data including incurred claims, processing status and payment timeliness data
Documents distribution of capitation payments
Generates explanation of benefits, remittance advice, and statements
Data for provider payment issuance purposes
Escalation Tracking System (ETS)
Facilitates administration and escalation management and processing of claim disputes, grievances and appeals. ETS:
Manages, provides status and tracks resolution on submitted grievances and appeals against policy-mandated time frames for Enrollee contact and appeal or grievance resolution
Generates reports related to the outcomes of grievances, complaints and appeals
Provides flexibility to easily customize data elements according to the Commonwealth’s needs
MACESS Workflow application that facilitates claim processing, including viewing of paper claims and supporting documentation in EDMS, and routing of claims to our claim processors
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Information System
RFP 758 2000000202 Page 13 of 31
Management Information System General Description/Functions Supported by System
National Encounter Management Information System (NEMIS)
Strategic, internally developed encounter data submission and reporting system that initiates submission of encounters, tracks responses, provides error correction and resubmission of Medicaid encounters to the Commonwealth in a format to be specified by the Commonwealth.
Network Database (NDB) Our single enterprise repository of all information related to provider network management
NetworX Supports rules-based provider contract configuration and claim pricing
Optum Transaction Validation Manager (OTVM)
Electronic data interchange (EDI) validation that enables us to test and certify HIPAA transaction sets and verify compliance with standards and regulations on inbound claims.
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Information System
RFP 758 2000000202 Page 14 of 31
Subcontractor Integration
(Vision, Dental, RX)
Claims Platform
Acknowledgement sent to Provider
Paper Claims via RMO
2
Claims Subsystem
Claims Routing(CHWY/CPE)
997/999ACK
837 Claim
EDI Claims via Clearing House(Optum ENS)
1
HIPAA SNIP Validations
(OTVM)
3
Claims Pre-Processing
(CSP Facets)
7
Claims Adjudication(CSP Facets)
9
Claims Payment(CSP Facets)
10
Encounters Processing(NEMIS)
11
Adjust and Recovery
Operations(ARO)
12
837 Claim
Processed ClaimsWorkflow Mgmt.
(MACESS & Facets Workflow)
NSF/UB Claim
8
All Claims
Claims with Pre-Processing errors
Commonwealth(KY)
Single and Batch
Adjustments
4
Claims Rules Engine (CRE)
Encounters Reporting
HIPAA Compliant EDI claims are received at clearinghouse.
Electronic claims are checked for compliance and are validated with HIPAA SNIP validations
Claims are routed to appropriate claims system based on the Enrollee identifiers
Claims with pre-processing errors are routed to MACESS or Facets Workflow for manual review and updates. Updated claims are processed in the next cycle
Adjudication ready claims are picked up and processed. Claim editing rules are applied. Authorization is verified. Provider contract and pricing is determined. Enrollee benefits, co-pays, deductible, and max out of pocket are verified and applied
Paper claims are scanned and converted to electronic form. Basic validations are applied
Check creation / EFT generation
1
2
3
4
8
9
10
Encounters are created for finalized claims and are validated prior to sending to the Commonwealth
11
Applicable claims amounts are applied to an enrollee�s deductible and copayment account details are applied for subcontractor claims
6 12 Adjustments are categorized into single and batch. Single adjustments are done directly via Facets online application. Batch adjustments are done via bulk adjustment tool
5
Claim is checked against various claim edits, validations, and rules.
5
6
Claims
Claim is loaded into Facets pre-processer. Enrollee and Provider on the claim are identified
7
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Information System
RFP 758 2000000202 Page 15 of 31
Encounters Subsystems
UnitedHealthcare HIPAA Validation
(OTVM)
Claims Adjudication
Engine(CSP)
3
Encounter System(NEMIS)
4
Commonwealth Processing
(KY)
5
Claims Claims 837 FilesNCPDP
Encounters Response
2
Response Processing(NEMIS)
Encounters Triage & Correction
(NEMIS)
67
Corrections
Claims Intake(Clearinghouse /
Paper)Claims
1
Enrollee Files (834)
Provider Data(NDB)
Claims Intake(Subcontractor
Claims – Vision, Dental, Rx)
Subcontractor Claims
(Vendor DB)
SubcontractorClaims
Corrections
EDI and paper claims are received
Encounters are created for finalized claims and are validated prior to sending them to State
The Commonwealth processes submitted encounters and sends response via ECG
Response received from the Commonwealth is processed. Encounters are identified for corrections
Adjudication ready claims are processed and payments made
Identified encounters are triaged, corrected, and resubmitted for processing. Root causes identified. Subcontractor encounter identification and notification
1
3
4
5
6
7
Electronic claims are checked for compliance and are validated with HIPAA SNIP validations
2
Triage Solutions
Adjustments
Payment Integrity Edit / Recoveries
Claims Processing Procedure Changes
Configuration Changes
Provider Data Collection
Clearinghouse Edits
IT Claim Edits
Subcontractor Error Notification and Correction
Subcontractor Encounter ErrorsAncillary
Subcontractors
State Provider Data
Encounter Response Triage
Root Cause Analysis
Validate with Companion Guide
Validate against other State rules / requirements
Subcontractor encounter error Identification
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Attachment C.6.a UnitedHealthcare Management
Information System
RFP 758 2000000202 Page 16 of 31
C.6.a.vi. Financial Subsystem The flowchart below depicts how our financial subsystems interconnect with our claims platform, payment and invoicing, pricing, reporting and other systems related to finance management and business accounting practices. Following the summary table below, we provide a flowchart that illustrates the subsystems that interconnect with subsystems for operational support regarding finance, accounting, pricing and similar financial management practices and activities.
Table C.6.a.vi.: Financial Subsystem Descriptions
Management Information System General Description/Functions Supported by System
Subsystems: Financial
B2B/Electronic Communication Gateway (ECG)
Suite of tools supporting secure EDI transactions and file transfers between UnitedHealthcare and external parties
CSP Facets Integrated managed care information system built on the TriZetto Facets platform, which meets all applicable state and federal laws and privacy regulations including, but not limited to, HIPAA. Functions include:
Core health plan administration system’s primary functions: benefits, enrollment and disenrollment management, claims pricing, adjudication and payment
Comprehensive Enrollee database, using Medicaid state ID numbers; eligibility begin and end dates; age-specific information; enrollment history; Enrollee TPL coverage and utilization and expenditure information
Integrated claim processing suite including claim edits, adjudication, COB processing, rules-based correction/adjustment, voiding and resubmission
Claim status data including incurred claims, processing status and payment timeliness data
Documents distribution of capitation payments
Generates explanation of benefits, remittance advice, and statements
Data for provider payment issuance purposes
Financial Summary Database (FSDB) Manages financial transactions to our general ledger and reserving process
Financial Tagging Service (FTS) The FTS increases the consistency and quality of financial tags in analytic data warehouses and financial tools
National Encounter Management Information System (NEMIS)
Strategic, internally developed encounter data submission and reporting system that initiates submission of encounters, tracks responses, provides error correction and resubmission of Medicaid encounters to the Commonwealth in a format to be specified by the Commonwealth.
Payment Engine Processes and generates consolidated check and electronic payments (EFT) to providers along with provider remittance advices (PRA) and electronic remittance advices (ERA) per provider preference.
PeopleSoft Enterprise financial management solution containing modules, such as general ledger, asset management, purchasing, accounts payable and accounts receivables, to provide a consolidated view of financial data
Revenue Accuracy Manager (RAM) RAM reconciles Enrollee records to capitation payments and documents receipt and distribution of capitation payments
Helping People Live Healthier Lives
Medicaid Managed Care Organization (MCO) – All Regions
Attachment C.6.a UnitedHealthcare Management
Information System
RFP 758 2000000202 Page 17 of 31
Claims Platform
Financial Subsystems
Claims Pre-
Processing
(CSP Facets)
1
Claims
Adjudication
(CSP Facets)
2
Claims Payment
(CSP Facets)
3 Claims,
Payments
Corporate Finance and General Ledger
GL Tagging
(FTS, UDW)
7
Financial
Reporting
(FSDB)
8
Treasury
(PeopleSoft)
9
ACHElectronic Remits
(EPS)
4
835 Paper
Remits
Paper Remits
(Print Services)
5
Check Printing
(Print Services)
6
Checks
Send EFT
Payment
(MCO�s Bank)
10
EFT
Receive EFT
Payment
(Provider�s Bank)
11
Revenue
Reconciliation
(RAM)
13
820Eligibility,
Rate Cell
Payments & invoices
C&S Data
Warehouse and
Analytics
(SMART)
12Claims, Eligibility,
Providers, Finance
Print physical check and send them to providers
Adjudication-ready claims collected and processed according to
contract/provider/claims-specific rules and configurations (e.g.,
authorizations, pricing, benefits)
Run payment cycle and generate 835 to Payment Engine.
Payment Engine generates EFT and remit data
1
2
3
4
6
7
8
Corporate treasury functions9
5
MCO�s bank sends EFT payment through Automated Clearing
House (ACH) transaction10
Claim is loaded into Facets pre-processor. Enrollee and Provider
on the claim are identified
Processing electronic remits (835) and send them to providers
Print paper remits (provider EOB) and send them to providers
Perform GL tagging and make data available to FSDB
Financial reporting and forecasting
Providers bank receives EFT payment through Automated
Clearing House (ACH) transaction11
13 Invoice per Enrollee is generated and matched against payment
from State to perform revenue reconciliation
14
Data Warehouse and Business Intelligence (BI) reporting12
Payment
Processing
(Payment Engine)
835
Payments to
Commonwealth
(KY)
The Commonwealth sends payments (820 file) to
UnitedHealthcare
14
Helping People Live Healthier Lives
Medicaid Managed Care Organization (MCO) – All Regions
Attachment C.6.a UnitedHealthcare Management
Information System
RFP 758 2000000202 Page 18 of 31
C.6.a.vii. Utilization/Quality Improvement Subsystem Following the table below, we provide flowcharts that depict how our utilization data and quality improvement subsystems are interconnected, enabling our population health management teams to have access to historic, current and trending utilization and outcomes data to guide their approach to implementing or adjusting utilization management and quality improvement initiatives at a population-specific level.
Table C.6.a.vii.: Utilization Data and Quality Improvement Subsystem Descriptions
Management Information System General Description/Functions Supported by System
Subsystem: Utilization Data and Quality Improvement
Blended Census Reporting Tool (BCRT)
The Blended Census Reporting Tool (BCRT) is a census report tool that tracks open cases and discharges daily by minor market and region. It serves as an operational and analytical tool to support bed day management initiatives.
B2B/Electronic Communication Gateway (ECG)
Suite of tools supporting secure EDI transactions and file transfers between UnitedHealthcare and external parties
ClaimSphere HEDIS ClaimSphere™ HEDIS is Cognizant’s NCQA-certified HEDIS solution. ClaimSphere:
Provides the foundation for medical quality management and improvement programs like provider profiling and gaps-in-care analysis
Performs detailed measure analysis with access to Enrollee detail and information on specific Enrollees qualified for each measure
Standard system views provide us with insight through line of business analysis, gaps-in-care reporting, provider scorecards and drill down capabilities. With this information transparency insight, we can analyze poorly performing measures to take appropriate action.
We broadcast gaps in care via our secure provider and Enrollee portals, mobile app, EDI eligibility transactions and CommunityCare.
Helping People Live Healthier Lives
Medicaid Managed Care Organization (MCO) – All Regions
Attachment C.6.a UnitedHealthcare Management
Information System
RFP 758 2000000202 Page 19 of 31
Management Information System General Description/Functions Supported by System
CommunityCare This tool enables care coordination, medication management and quality management by giving providers updated and shared access to Enrollee’s (i.e., their patient’s) care plan and supports alignment of clinical problems, goals and interventions. It provides electronic access for the care team, primary care coordinators, providers, specialists, Enrollees, caregivers and others, as permitted by the Enrollee. Containing claims information from CSP and authorization data from ICUE, CommunityCare includes our Population Registry and gives providers and care communities a comprehensive view of the services used by any given care population. Using the Enrollee view within the Population Registry, providers have the clinical history of the whole person. CommunityCare:
Provides automated notifications of care transitions
Receives authorizations from ICUE for reference by the care team
Supports Direct for secure clinical data exchange with providers and HIEs
Supports import, parsing and attachment of C-CDA, ADT, LOINC and other standard formats
CSP Facets Integrated managed care information system built on the TriZetto Facets platform, which meets all applicable state and federal laws and privacy regulations including, but not limited to, HIPAA. Functions include:
Core health plan administration system’s primary functions: benefits, enrollment and disenrollment management, claims pricing, adjudication and payment
Comprehensive Enrollee database, using Medicaid state ID numbers; eligibility begin and end dates; age-specific information; enrollment history; Enrollee TPL coverage and utilization and expenditure information
Integrated claim processing suite including claim edits, adjudication, COB processing, rules-based correction/adjustment, voiding and resubmission
Claim status data including incurred claims, processing status and payment timeliness data
Documents distribution of capitation payments
Generates explanation of benefits, remittance advice, and statements
Data for provider payment issuance purposes
eVisor/Impact Pro PP
TM PP (IPRO) eVisor synchronizes claims data with evidence-based medicine guidelines to identify engagement opportunities.
Impact Pro is a key analytical engine within the eVisor analytics platform. Impact Pro is a multidimensional, episode-based predictive modeling and care management analytics solution that enables our nurse care managers to use clinical, risk and administrative profile information to provide targeted health care service to Enrollees. Impact Pro:
Identifies individuals who have not obtained appropriate preventive care and screening and who are at risk for developing costly and debilitating health conditions
Provides Enrollee risk stratification and scoring to target specific populations/individuals for different levels of care management intensity managed through CommunityCare and ICUE
Provides results through CommunityCare
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Attachment C.6.a UnitedHealthcare Management
Information System
RFP 758 2000000202 Page 20 of 31
Management Information System General Description/Functions Supported by System
Healthify Web-based tool that helps us connect enrollees to relevant and available social resources that deliver services (e.g., food, housing, legal resources, employment assistance, energy, support groups, child care and clothing) to individuals at risk for poor health outcomes or inappropriate use of health care services.
ICUE ICUE (Integrated Clinical User Experience) is our clinician-facing web-based clinical platform that enables and delivers a coordinated, integrated experience to our Enrollees and the health care communities that support them. ICUE features consolidated data, functions and user experience and serves as a single source of truth for clinical operations transactional data. System users have access to all of the categories of data they need, such as Enrollee eligibility, benefits, provider information, claims data and clinical resources.
Link Secure provider portal providing a central access point where enrolled providers have access to eligibility and benefits, claims management, claims reconsiderations, enhanced online authorizations and gaps in care, and where they can update their practice profile. Also, providers can view and provide feedback on the initial health risk screening and care plans in CommunityCare.
Network Database (NDB) Our single enterprise repository of all information related to provider network management
Secure Enrollee Portal (myuhc.com) Secure health and wellness information is available 24 hours a day, seven days a week through our Enrollee portal. Enrollees register for online access by setting up a secure HealthSafe ID™ and password. The personalized and easy-to-navigate digital experience allows Enrollees to search for covered benefits (medical, dental, vision, pharmacy and mental health), manage personal preferences, update contact information (including email addresses for facilitating contacts and information exchange), view/print and request we mail an ID card, change their PCP and locate providers through a searchable provider directory. Also, the portal offers personalized health and wellness content such as seasonal reminders (i.e., flu shots), personalized care recommendations, links to plan programs, and links to online resources and tools.
Strategic Management Analytic Reporting Tool (SMART)
Comprehensive, integrated analytical data warehouse, using the latest Oracle Exadata Database platform that holds all Medicaid relevant information — including claims data (e.g., medical, pharmacy, vision and lab), Enrollee data, provider data, authorizations, external subcontractor data and predictive modeling information. SMART:
Supports quality management, performance management and compliance reporting, and ad hoc reporting as needed with turnaround times averaging less than five business days
Stores service-specific data that includes behavioral health, LTSS, pharmacy, inpatient and outpatient services
Includes consolidated patient census (common store of all patients receiving care)
Consolidates data for Impact Pro health-risk modeling and stratification
Consolidates relevant data for ClaimSphere EPSDT and HEDIS reporting and related analysis and monitoring
Helping People Live Healthier Lives
Medicaid Managed Care Organization (MCO) – All Regions
Attachment C.6.a UnitedHealthcare Management
Information System
RFP 758 2000000202 Page 21 of 31
Risk Stratification(IPRO)
Clinical Platforms
ICUE
6
CommunityCare
Secure Provider Portal
(Link)
Auths
Claims System(CSP Facets)
HEDIS Measures(ClaimSphere)
HRAPlan of CarePrior Auths
278 Auth
Notifications
Risk Scores
UM, CM Data
CommunityCare tool supports care coordination
Authorizations fed to claims system to support adjudication. Enrollee and network data fed to clinical systems
2
3
4
5
8
9
Providers can submit 278 EDI authorization. Acknowledgements are sent from B2B
Providers can submit authorization requests, view status and more on various Link applications
Utilization Management, assessments and reviews
10
Clinical Reporting and Analytics
Secure Enrollee Portal
(myuhc)
1
Enrollees can view or update HRA, Plan of Care, IHR, and more on myuhc.com
11
12
Healthify tool supports social determinates of health
Utilization Data and Quality Improvement Subsystems
ProviderProvider Data
(NDB)
10
Claims, Providers, Enrollees
Data Warehouse and Analytics
(SMART)
13
13
Risk stratification of Enrollees. Risks shared with CommunityCare for high risk Enrollees
Provider,Enrollee,Claims
11
ADT, CM Data
Enrollee, Provider, Claims,
2
3
5
6
7
HIE, EMR connections, and other systems deliver ADT and CM data via ECG
Provider data is made available to clinical systems
7
KHIE, HIEs, Provider Groups,
Hospitals
1
Blended Census Reporting Tool
(BCRT)
9
Prior Auth Intake(B2B, EDI,
Clearinghouse, Portals)
412
Healthify
8
Claim, Enrollee, Provider, RX, Labs, and supplemental data loaded for HEDIS in ClaimSphere
Notifications sent from BCRT tool to Clinical Platform
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Attachment C.6.a UnitedHealthcare Management
Information System
RFP 758 2000000202 Page 22 of 31
C.6.a.viii. Surveillance Utilization Review Subsystem Our comprehensive Surveillance Utilization Review Subsystem (SURS) captures enrollee-specific and provider specific information (including subcontractor information) and complies with the requirements of 42 CFR 455. The diagram following the table below shows how our SURS supports a multitude of quality improvement, utilization management, profiling, reporting, investigating, and monitoring activities aimed at reducing fraud, waste and abuse and continuous quality improvement.
Table C.6.a.viii.: Surveillance Utilization Review Subsystem Descriptions
Management Information System General Description/Functions Supported by System
Subsystem: Surveillance Utilization Review
B2B/Electronic Communication Gateway (ECG)
Suite of tools supporting secure EDI transactions and file transfers between UnitedHealthcare and external parties
Claims Processing Engine (CPE) Application that enables universal claim intake and routing into CSP
Cotiviti Clinical edit system which analyzes provider health care claims based upon business rules and edits.
CSP Facets Integrated managed care information system built on the TriZetto Facets platform, which meets all applicable state and federal laws and privacy regulations including, but not limited to, HIPAA. Functions include:
Core health plan administration system’s primary functions: benefits, enrollment and disenrollment management, claims pricing, adjudication and payment
Comprehensive Enrollee database, using Medicaid state ID numbers; eligibility begin and end dates; age-specific information; enrollment history; Enrollee TPL coverage and utilization and expenditure information
Integrated claim processing suite including claim edits, adjudication, COB processing, rules-based correction/adjustment, voiding and resubmission
Claim status data including incurred claims, processing status and payment timeliness data
Documents distribution of capitation payments
Generates explanation of benefits, remittance advice, and statements
Data for provider payment issuance purposes
Escalation Tracking System (ETS)
Facilitates administration and escalation management and processing of claim disputes, grievances and appeals. ETS:
Manages, provides status and tracks resolution on submitted grievances and appeals against policy-mandated time frames for Enrollee contact and appeal or grievance resolution
Generates reports related to the outcomes of grievances, complaints and appeals
Provides flexibility to easily customize data elements according to the Commonwealth’s needs
MACESS Workflow application that facilitates claim processing, including viewing of paper claims and supporting documentation in EDMS, and routing of claims to our claim processors
MedReview Reviews the validity and appropriateness of high-dollar claims
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Attachment C.6.a UnitedHealthcare Management
Information System
RFP 758 2000000202 Page 23 of 31
Management Information System General Description/Functions Supported by System
NetworX Supports rules-based provider contract configuration and claim pricing
OptumInsight Claim Edit System (iCES)
Clinical edit system that analyzes provider health care claims based upon business rules that automate reimbursement policy and industry standard coding practices
Optum Transaction Validation Manager (OTVM)
Electronic data interchange (EDI) validation that enables us to test and certify HIPAA transaction sets and verify compliance with standards and regulations on inbound claims.
Prospective 2.0 Identifies fraud and abuse prior to claims payment allowing a greater recovery than post-payment
Sanctions DB Monitors provider sanctions and disciplinary actions.
Smart Audit Master (SAM) Claims payment validation tool that screens for the most common errors
Strategic Management Analytic Reporting Tool (SMART)
Comprehensive, integrated analytical data warehouse, using the latest Oracle Exadata Database platform that holds all Medicaid relevant information — including claims data (e.g., medical, pharmacy, vision and lab), Enrollee data, provider data, authorizations, external subcontractor data and predictive modeling information. SMART:
Supports quality management, performance management and compliance reporting, and ad hoc reporting as needed with turnaround times averaging less than five business days
Stores service-specific data that includes behavioral health, LTSS, pharmacy, inpatient and outpatient services
Includes consolidated patient census (common store of enrollees receiving care)
Consolidates data for Impact Pro health-risk modeling and stratification
Consolidates relevant data for ClaimSphere EPSDT and HEDIS reporting and related analysis and monitoring
Helping People Live Healthier Lives
Medicaid Managed Care Organization (MCO) – All Regions
Attachment C.6.a UnitedHealthcare Management
Information System
RFP 758 2000000202 Page 24 of 31
Claims Platform
Acknowledgement sent to Provider
Paper Claims via RMO
2
Surveillance Utilization Review Subsystem (SURS) Subsystem
997/999ACK
837 Claim
EDI Claims via Clearing House(Optum ENS)
1
HIPAA SNIP Validations
(OTVM)
3
Claims Pre-Processing
(CSP Facets)
8
Claims Adjudication(CSP Facets)
9
Claims Payment(CSP Facets)
10
Reporting and Analytics(SMART)
837 Claim
NSF/UB Claim
All Claims
State Reports(Commonwealth)
Claims Routing(CHWY/CPE)
HIPAA Compliant EDI claims are received at clearinghouse.
Electronic claims are checked for compliance and are validated with HIPAA SNIP validations
Claims are routed to appropriate claims system based on the Enrollee identifiers
Claims are picked up and processed. Claim editing rules are applied. Authorization is verified. Sanctioned providers claims are denied. Provider contract and pricing is determined. Enrollee benefits, co-pays, deductible, and max out of pocket are verified and applied.
Paper claims are scanned and converted to electronic form. Basic validations are applied
Randomly sampled claims routed to auditors, transaction operations and quality which opens claims, review errors and determine a claim's accuracy assessment. DRG Payment Accuracy is assessed
1
2
3
4
9
10
11
12
6
Single adjustments are done directly via Facets online application. Batch adjustments are done via bulk adjustment tool
13
14
5
Claim is checked against various claim edits, validations, and rules. 5
Claim is loaded into Facets pre-processer. Enrollee and Provider on the claim are identified
7
Claims Auditing(SAM,
MedReview)
13
Clinical editing and reimbursement policies are applied to claims.
8
15
Flagged claims are processed/denied due to fraudulent or abusive activity
Check creation / EFT generation
4
Clinical Edits(Cotiviti and ICES)
14
Detect Fraud, Waste and Abuse
(P2)
11 Pricing and Groupers(Networx/Webstrat/
EasyGroup)
12
Provider Sanction Check
(Sanctions DB)
7Initial Screen for
Fraud, Waste and Abuse
(Prospective 2.0)
6
Claims Rules Engine (CRE)
5
Claims are priced and classified
Claim is flagged if fraud, waste, or abuse is detected
Claim is flagged if provider has been sanctioned
16Claims information is copied into Data Warehouse and to adjustment recovery operations for analytics and reporting
Adjust and Recovery
Operations(ARO)
15
Single and Batch Adjustments
16
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Attachment C.6.a UnitedHealthcare Management
Information System
RFP 758 2000000202 Page 25 of 31
C.6.a.ix. Reporting Subsystems The flowcharts following the table below depict current and next generation systems for how enrollee, provider, internal and external (i.e., state data intake, subcontractor) data from our eligibility, enrollment, claims, and utilization management subsystems is extracted, transformed and loaded into our SMART data warehouse. Our business intelligence team and end-users access SMART and use its data analytics toolset to analyze data and to produce reports that are shared internally and externally. The table below provides a summary of SMART and our electronic communication gateway (ECG) that supports reporting and secure data transactions with external parties.
Table C.6.a.ix.: Reporting Subsystem Descriptions
Management Information System General Description/Functions Supported by System
Subsystem: Reporting
Artificial Intelligence and Machine Learning
Information is extracted from data automatically through computational and statistical methods for use in Natural Language Processing, ChatBots, Robotic Process Automation, Expert Systems and Recommendation Engines
B2B/Electronic Communication Gateway (ECG)
Suite of tools supporting secure EDI transactions and file transfers between UnitedHealthcare and external parties
Data Fabric A standardized technological approach to transport, transform, integrate and enrich source data on the way to being stored
Data Services Layer The Data Services Layer provides access to our processed information through the use of application programming interfaces (APIs), for use by internal applications and other tools
Hotspotting Tool Analytical tool used to identify enrollees to target for specific interventions.
Strategic Management Analytic Reporting Tool (SMART)
Comprehensive, integrated analytical data warehouse, using the latest Oracle Exadata Database platform that holds all Medicaid relevant information — including claims data (e.g., medical, pharmacy, vision and lab), Enrollee data, provider data, authorizations, external subcontractor data and predictive modeling information. SMART:
Supports quality management, performance management and compliance reporting, and ad hoc reporting as needed with turnaround times averaging less than five business days
Stores service-specific data that includes behavioral health, LTSS, pharmacy, inpatient and outpatient services
Includes consolidated patient census (common store of all patients receiving care)
Consolidates data for Impact Pro health-risk modeling and stratification
Consolidates relevant data for ClaimSphere EPSDT and HEDIS reporting and related analysis and monitoring
Helping People Live Healthier Lives
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Attachment C.6.a UnitedHealthcare Management
Information System
RFP 758 2000000202 Page 26 of 31
Predictive Modeling and Stratification(ImpactPro)
SMART Analytics Toolset (MicroStrategy,
Crystal, Excel, etc)
Data Warehouse and Analytics
(SMART)
Reporting Subsystem
Provider, Enrollee, and
Claims Processing(CSP Facets)
Subcontractor Data ( Vision,
Dental, Rx, Lab, etc.)
Processed Claims
1
2
Claims, Providers, Enrollee Data
Utilization and Care
Management (ICUE,
CommunityCare)
3
Operational Environment
Inpatient/Outpatient
Auths
Extract, Transform, and Load Process
Reports and Data Analysis
Data is extracted and loaded into ClaimSphere for calculations of our HEDIS scores and Gaps in Care
Data is extracted and loaded into ImpactPro used in predictive modeling and stratification
1
2
3
5
6Subcontractor Claims (pharmacy, vision, dental, lab, etc.) are sent to SMART
Medical claims, behavioral claims, Enrollee demographics, provider demographics are sent to SMART
Utilization and Care Management are sent to SMART
7
7
The Business Intelligence team and end-users will access SMART and Operational systems using the Analytic Toolsets
5
HEDIS Measures and Gaps in Care
(ClaimSphere)
6
Commonwealth�s Data(KY)
Historical Data
Enrollee Segmentation and
Targeting(Hotspotting Tool)
4
8
Historical Commonwealth data can be loaded into SMART for analytical purposes
4 Data is loaded to our Hotspotting tool which identifies and targets enrollees for specific intervention
8
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Attachment C.6.a UnitedHealthcare Management
Information System
RFP 758 2000000202 Page 27 of 31
Artificial
Intelligence and
Machine Learning
Data Services
Layer
Cloud-based Data
Storage
Reporting Subsystem: Next Generation
Provider,
Enrollee, and
Claims Processing
(CSP Facets)
Subcontractor
Data ( Vision,
Dental, Rx, Lab,
etc.)
Processed
Claims
1
2
Claims, Providers,
Enrollee Data
Utilization
and Care
Management
(ICUE,
CommunityCare)
3
Operational
Environment
Inpatient/
Outpatient
Auths
Data Fabric
(Data Intake)
Data available for
application and
reporting
consumption
Data loaded into virtually unlimited UnitedHealthcare�s
Cloud-based storage
Information is extracted from data automatically through
computational and statistical methods for use in Natural
Language Processing, ChatBots, Robotic Process
Automation, Expert Systems and Recommendation
Engines
1
2
3
5
6
Subcontractor Claims (pharmacy, vision, dental, lab,
etc.) are sent to Big Data storage
Medical claims, behavioral claims, Enrollee
demographics, provider demographics are sent to Big
Data storage
Utilization and Care Management are sent to Big Data
storage
8
8
A standardized technological approach to transport,
transform, integrate and enrich source data on the way
to being stored
5
Data Warehouse
and Analytics
(SMART)
Analytic Tools
4
9
Existing data in SMART system is made available to the
Big Data platform
4 Many tools are available for the review and analysis
including Splunk, Talend, MapR, MarkLogic, Tableau
9
10
6
Big Data Environment
Provides access to our processed information through
the use of application programming interfaces (APIs),
for use by internal applications and other tools.
10
Enriched Data
Repository
7
Data is enhanced, refined, and improved creating a
valuable asset for use in analytics and reporting
7
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Attachment C.6.a UnitedHealthcare Management
Information System
RFP 758 2000000202 Page 28 of 31
C.6.a.x. Testing Subsystems The diagram following the table below depicts our systems testing methodology. Following the diagram, we provide a flowchart of our encounter data testing processes. The summary table below provides descriptions of our subsystem testing methodologies, including those for ensuring encounter data is complete, accurate, and delivered on time.
Table C.6.a.x.: Testing Subsystem Descriptions
Management Information System General Description/Functions Supported by System
Subsystem: Testing Methodology
Automated Testing To help improve quality while reducing cost, this effort advocates the expansion of automated testing within UnitedHealth Group information technology leveraging consistent, advanced frameworks.
Client Acceptance Testing Client acceptance testing occurs after all the validation of any new capabilities is complete. This ends the cycle and provides consent to promote the software for production use.
Client Integration and Regression Testing
Once internal testing of the changes is complete, client integration (for new items) and client regression testing is executed. Any issues uncovered are reported and, in needed, added to the sprint backlog to be addressed.
Software Development Life Cycle (SDLC)
Our SDLC approach affords a smooth and timely implementation of new health plan programs or system modifications. We use an Agile software development framework (Scalable Agile Method) comprising intellectual capital and assets for processes, tools, metrics and training for reliable changes with minimum time to deployment.
Sprint Throughout the sprinting phase, the development team completes a series of short sprints to create and release working software according to backlog specifications and the program increment milestones. This includes analysis, design, coding and testing of the item from the sprint backlog. Issues uncovered during the testing are placed on the sprint backlog to be addressed.
Encounters System Test Example This is an example of testing points using the Encounters subsystem. Refer to C.6.a.iii for Encounter Subsystem definitions.
Testing Standards/Best Practices We define the optimum methodologies and approaches for quality assurance in a manner that can adapt to multiple technologies and implementation approaches. We also capture and communicate successful approaches, or best practices that we can better leverage throughout the organization.
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Attachment C.6.a UnitedHealthcare Management
Information System
RFP 758 2000000202 Page 29 of 31
User Story Analysis
Software Design and Test Design
Software Build
Test Execution
Defect Reporting
(placed on sprint backlog)
Sprint Tasks
KY Acceptance
Testing
KY Integration and
Regression
Testing
Backlog
KY Defect
Reporting
UnitedHealthcare Scaled Agile Method
Testing Subsystem
Testing Subsystem
UnitedHealthcare uses an Agile approach to developing software leveraging Acceptance Test Driven Development (ATDD). In applying ATDD, teams build
testing into the software delivery lifecycle. User stories provide the backdrop for the testing scenarios needed to validate the desired functionality. Coding
changes are validated through a combination of manual and automated testing as defined in the user stories, after each software build. Defects found are placed
back on the sprint backlog to be remediated. Once unit and functional testing is complete, client integration testing can begin. Security, performance and
scalability are validated throughout the testing lifecycle to ensure the highest quality deliverables.
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Attachment C.6.a UnitedHealthcare Management
Information System
RFP 758 2000000202 Page 30 of 31
Testing Points within the Encounters Subsystem
UnitedHealthcare
Front End /
HIPAA Edits
(OTVM)
Claims
Adjudication
Engine
(CSP)
Encounter System
(NEMIS)
2
Commonwealth
Processing
(KY)
1
Claims Claims
837's
NCPDP
Encounters
Response
2
Response
Processing
(NEMIS)
Encounters Triage
& Correction
(NEMIS)
Corrections
Claims Intake
(Clearinghouse /
Paper) Claims
Enrollee Files
(834)
Provider Data
(NDB)
Claims Intake
(Subcontractor
Claims – Vision,
Dental, Rx)
Subcontractor
Claims
(Vendor DB)
Subcontractor
Claims
Corrections
Subcontractor Encounter ErrorsAncillary
Subcontractors
Contains functional tests for stories, features, and capabilities, to validate that they work the way the Product Owner (or
Customer/user) intended. Feature-level and capability-level acceptance tests confirm the aggregate behavior of many user
stories. This is testing for new functionality or connectivity. This includes unit, component and connectivity testing
Contains system-level acceptance tests to validate that the behavior of the whole system meets usability and functionality
requirements, including scenarios that are often encountered during system use. This is testing of systems that have no change
or only configuration-based changes. This includes business oriented system integration, usability and user acceptance testing
1
2
Contains system qualities testing to verify the system meets its Nonfunctional Requirements (NFRs), such as load and
performance. This is testing that is used to ensure that connectivity to external entities is secure and performant. This includes
performance load and security testing
3
2
3
1 2
3
1 2
3
1 2
3
2
22
2
1 2
3
1
3
1
3
State Provider Data
Helping People Live Healthier Lives
Medicaid Managed Care Organization (MCO) – All Regions
Attachment C.6.a UnitedHealthcare Management
Information System
RFP 758 2000000202 Page 31 of 31
C.6.a.xi. Information Systems Management ServiceNow is our IT service management platform for our IT Support/Request Center and IT service management processes, including system monitoring and reporting of critical incidents. It supports all UnitedHealth Group employees, providers, subcontractors and the Department’s representatives by providing web-enabled forms for submitting business requests and incidents to the technology team. The Request Center is a module within our ServiceNow ITSM tool. A Request Item (RITM) and Request Task(s) (SCTASK) are created based upon the request made via the corresponding Request Center request item. All requests are properly logged, triaged, prioritized, assigned and managed to resolution using our other ITSM processes, such as incident and problem management.